Skip to main content

Main menu

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
    • Special Collections
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Tips for Writing About Programs in GHSP
      • Local Voices Webinar
      • Connecting Creators and Users of Knowledge
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers

User menu

  • My Alerts

Search

  • Advanced search
Global Health: Science and Practice
  • My Alerts

Global Health: Science and Practice

Dedicated to what works in global health programs

Advanced Search

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
    • Special Collections
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Tips for Writing About Programs in GHSP
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Alerts
  • Find GHSP on LinkedIn
  • Visit GHSP on Facebook
  • RSS
ORIGINAL ARTICLE
Open Access

Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation

Neena Shah More, Anagha Waingankar, Sudha Ramani, Sheila Chanani, Vanessa D'Souza, Shanti Pantvaidya, Armida Fernandez and Anuja Jayaraman
Global Health: Science and Practice March 2018, 6(1):103-127; https://doi.org/10.9745/GHSP-D-17-00182
Neena Shah More
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Anagha Waingankar
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sudha Ramani
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sheila Chanani
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Vanessa D'Souza
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Shanti Pantvaidya
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Armida Fernandez
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Anuja Jayaraman
aSociety for Nutrition, Education and Health Action, Mumbai, India.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: anuja.jayaraman@gmail.com
PreviousNext
  • Article
  • Figures & Tables
  • Supplements
  • Info & Metrics
  • Comments
  • PDF
Loading

Figures & Tables

Figures

  • Tables
  • Additional Files
  • FIGURE 1.
    • Download figure
    • Open in new tab
    • Download powerpoint
    FIGURE 1.

    Organogram of SNEHA CMAM Program, January–March 2016

    Abbreviations: CMAM, Community-based Management of Acute Malnutrition; M&E, monitoring and evaluation; SNEHA, Society for Nutrition, Education and Health Action.

  • Figure
    • Download figure
    • Open in new tab
    • Download powerpoint

    Frontline health workers from the Society for Nutrition, Education and Health Action and Integrated Child Development Services conduct a group session together. © 2015 Aahar field team/SNEHA

  • FIGURE 2.
    • Download figure
    • Open in new tab
    • Download powerpoint
    FIGURE 2.

    Success Factors of the SNEHA CMAM Program

    Abbreviations: CMAM, Community-based Management of Acute Malnutrition; SNEHA, Society for Nutrition, Education and Health Action.

  • Figure
    • Download figure
    • Open in new tab
    • Download powerpoint

    Frontline health workers were constantly present in the community, repeatedly sharing information. © Aahar field team/SNEHA

  • Figure
    • Download figure
    • Open in new tab
    • Download powerpoint

    Growth monitoring of an infant conducted by a frontline health worker. © Aahar field team/SNEHA

Tables

  • Figures
  • Additional Files
    • View popup
    TABLE 1.

    Overview of Program Activities

    ActivityDescription of Activity
    Growth monitoringSNEHA and ICDS frontline health workers jointly mobilized caregivers to bring children to the Anganwadi centers for monthly growth monitoring. The weight and height of all children in the community ages 0 to 6 years was measured. SNEHA frontline health workers used a mobile application to calculate weight-for-height nutrition grades and track information for children under age 3. Monthly growth monitoring enabled SNEHA frontline health workers to screen for severely and moderately wasted children and identify children at risk, including children faltering into malnutrition.
    Home visits by SNEHA frontline health workersSNEHA frontline health workers visited the homes of pregnant women and specific target groups of children under age 3 (severely wasted, moderately wasted, 0–6 months of age, and sick children). Caregivers, typically mothers, were counseled on various topics, including nutritious food habits and choices, age-appropriate nutrition, lactation and weaning, immunization, hygiene, and access to health services. SNEHA frontline health workers were trained on the topics of counseling and effective communication skills. Each target group had a specific protocol for the nature and frequency of visits, and program officers monitored the frequency and quality of the home visits.
    Community-based medical nutrition therapy distributionMedical nutrition therapy is a nutrient-dense dietary supplement for treating severely malnourished children. The peanut- and milk-based preparation was provided by the MCGM NRRC. Severely wasted or severely underweight and wasted children ages 7 to 36 months who have passed an appetite test and had no medical complications were eligible for medical nutrition therapy. Children were screened for complications by a pediatrician at a health camp or the NRRC before medical nutrition therapy treatment was initiated. Children were typically prescribed an 8-week treatment protocol with doorstep delivery of supplements and monitoring of consumption by SNEHA frontline health workers.
    Health campsPeriodic health camps were organized by SNEHA in community spaces where a pediatrician checked wasted and sick children referred by SNEHA frontline health workers. Doctors validated the nutrition grade of the child, screened for complications, treated illnesses, prescribed medical nutrition therapy, and referred children for inpatient care. Other children also accessed the camps for minor ailments.
    Referrals for MCGM and ICDS health servicesHealth posts are primary health facilities run by MCGM and responsible for numerous health prevention and promotion activities including distribution of iron-folic acid tablets and vitamin A syrup, deworming drives, immunizations, and detection and treatment of tuberculosis, leprosy, and malaria. SNEHA frontline health workers referred cases of illness and immunization to health posts and facilitated participation in deworming and vitamin A drives. The NRRC health facility is a center for inpatient and outpatient management of children with severe acute malnutrition; the NRRC validated the anthropometry conducted by SNEHA frontline health workers, conducted appetite tests and prescribed medical nutrition therapy, admitted and treated children with minor complications, and further referred children with severe complications to LTMGH, the tertiary MCGM hospital. SNEHA frontline health workers also referred children for services provided by ICDS including cooked meals and take-home rations.
    Group meetings and community eventsHealth behavior change activities were conducted in the community, in partnership with MCGM and ICDS, through games, group discussions, celebrations, cooking demonstrations, and screening of educational movies. Events included breastfeeding initiation ceremonies, baby shower celebrations, and International Breastfeeding and Nutrition week. Every 6 months, mothers whose children recovered and remained recovered from severe wasting were celebrated in the community.
    • Abbreviations: ICDS, Integrated Child Development Services; LTMGH, Lokmanya Tilak Municipal General Hospital; MCGM, Municipal Corporation of Greater Mumbai; NRRC, Nutrition Research and Rehabilitation Center; SNEHA, Society for Nutrition, Education and Health Action.

    • View popup
    TABLE 2.

    Data Collection Methods for the Qualitative Study

    CategoryDetailsThemes Explored
    In-depth interviews (N=37)
    Senior staffProgram head (discussion), implementation management (n=3), health camp doctor (n=1)General experiences with the program, its conceptualization and its components, changes in the program, perceived achievements and challenges, working in partnerships, and sustainability under different models of implementation.
    Health camp doctor: implementation of the camp, perceived benefits of the camp, challenges, and role of health camps in the program.
    Field teamSNEHA frontline health workers (n=6), SNEHA program officers (n=3)Sharing typical work-week activities and roles played, experiences, perceived achievements and challenges faced, and case illustrations.
    CommunityTotal interviews: 24
    Maximum diversity sample including mothers of severely wasted, moderately wasted, non-wasted, pregnant women; by age (0–6 years and above)/gender/religion; purposively sampled some complicated cases)
    Stories of interaction and familiarity with the program, perspectives (positive and negative) on various activities, suggestions for the program.
    Focus group discussions (N=3)
    Field team (SNEHA frontline health workers)3 focus group discussions, with 6 SNEHA frontline health workers per groupProtocols, time allocation to different activities, interaction with the community, program officers, and senior management.
    Observations (N=12 sessions)
    Home visits by SNEHA frontline health workersOver 2-week period: 8 visits, approximately 20 minutes eachGeneral processes, nuances of interaction with the community, process through which the SNEHA frontline health workers communicate information.
    Growth monitoringOver 2-week period: 4 sessions, half a day eachGrowth monitoring process in the Anganwadi centers, community mobilization, and management of crowd during weighing and taking of measurements.
    Site visitNRRC and urban health post, 1-time observationCrowd, physical infrastructure, placement of SNEHA staff at the NRRC, general familiarity of the field staff with the place.
    Descriptive monitoring data and case stories
    Descriptive monitoring dataAlready exists in the programSize and coverage of the program—number of beneficiaries, number of children monitored, number of home visits recorded.
    Case storiesAlready existed in the program to document successful cases to promote best practices. About 140 stories were recorded in 2015; we selected 46 diverse cases, translated them into English, and analyzed them.Interaction of the field team with caregivers, process of identification of malnutrition, intervention with the family.
    • Abbreviation: SNEHA, Society for Nutrition, Education and Health Action.

    • View popup
    TABLE 3.

    Household Demographics in Intervention and Comparison Areas at Endline, October–December 2015

    Intervention (N=3,455)aComparison (N=2,122)a
    Children
    Age, months, mean16.316.8
    Female, %46.347.6
    Low birth weight (<2.5 kg), %21.521.3
    Mothers
    Education, %
        Illiterate, primary, informal20.121.2
        Secondary (grades 5–10)56.757.7
        Higher secondary and above (grade 11  and above)23.221.0
    Not employed, %93.894.9
    Body mass index, mean22.822.3**
    Place of birth, %
        South India7.72.4***
        North and Central India17.529.2
        East and Northeast India12.05.1
        West India14.525.9
        Mumbai48.437.4
    Age at marriage, mean20.319.9*
    Households
    Years of residence in Mumbai, %
        Less than 1 year1.51.6
        1–5 years6.45.0
        6 or more years92.193.3
    Treatment of drinking water,b %32.932.1
    PPI: Likelihood below US$2.16/day/PPP line, %71.473.7**
    Private toilet, %20.415.8
    Food insecurity,c %21.718.1*
    Religion, %
        Muslim45.237.5
        Hindu49.957.1
        Other5.05.5
    • Abbreviations: PPI, Progress out of Poverty Index; PPP, purchasing power parity.

    • Pearson chi-square for categorical variables and t tests for means.

    • ↵* P≤.05; ** P≤.01; *** P≤.001.

    • ↵a Total sample sizes may vary due to missing values generated from data cleaning.

    • ↵b Treatment of drinking water includes chlorine, use of filter, solar disinfection, and boiling.

    • ↵c Question: “In the last month did you worry that your household would not have enough food?”

    • View popup
    TABLE 4.

    Wasting, Socioeconomic Status, and Coverage of Services in Intervention and Comparison Areas at Baseline (March–July 2014 for Intervention, September–November 2014 for Comparison) and Endline (October–December 2015)

    BaselineEndline
    Intervention (N=2,578)aComparison (N=2,092)aIntervention (N=3,455)aComparison (N=2,122)a
    Wasting, %18.016.913.016.0**
    Severe wasting, %3.83.32.33.9**
    Moderate wasting, %14.213.610.612.1
    PPI: Likelihood below US$2.16/day/PPP line, %72.677.3***71.473.7**
    Child received any service from SNEHA in previous month, %2.21.686.00.8***
    • Abbreviations: PPI, Progress out of Poverty Index; PPP, purchasing power parity; SNEHA, Society for Nutrition, Education and Health Action.

    • Pearson chi-square tests comparing baseline intervention to baseline comparison areas and endline intervention to endline comparison areas.

    • ↵* P≤.05; ** P≤.01; *** P≤.001.

    • ↵a Total sample sizes may vary due to missing values.

    • View popup
    TABLE 5.

    Multi-Level Logistic Regression Analysis of Household Demographics Associated With Wasting at Endline, October–December 2015

    Null Model (N=5,524)Unadjusted OR (N=5,524)Model 1a: AOR (95% CI) (N=4,913)Model 2a: AOR (95% CI) (N=4,889)Model 3a: AOR (95% CI) (N=4,869)
    β° (SE)0.154 (0.008)0.180 (0.013)1.122 (0.261)1.551 (0.798)0.673 (0.463)
    Children
    Resides in intervention area0.78 (0.64, 0.94)**0.80 (0.66, 0.97)*0.81 (0.67, 0.98)*0.81 (0.67, 0.99)*
    Age, months1.00 (0.99, 1.01)1.00 (0.99, 1.01)1.00 (0.99, 1.01)
    Female0.75 (0.63, 0.89)**0.75 (0.64, 0.89)**0.76 (0.64, 0.90)**
    Birth weight0.53 (0.46, 0.62)***0.56 (0.48, 0.65)***0.57 (0.49, 0.66)***
    Mothers
    Education
        Illiterate, primary, informal11
        Secondary (grades 5–10)0.75 (0.60, 0.93)**0.78 (0.63, 0.98)*
        Higher secondary (grade 11 and above)0.74 (0.57, 0.97)*0.82 (0.62, 1.09)
    Not employed1.05 (0.67, 1.66)1.04 (0.66, 1.64)
    Body mass index, mean0.96 (0.94, 0.98)***0.96 (0.94, 0.98)***
    Place of birth
        South India11
        North and Central India1.34 (0.87, 2.06)1.34 (0.86, 2.07)
        East and Northeast India1.60 (1.00, 2.54)*1.61 (1.00, 2.59)*
        West India1.23 (0.80, 1.89)1.21 (0.78, 1.87)
        Mumbai1.22 (0.82, 1.83)1.29 (0.86, 1.95)
    Age at marriage, mean1.02 (0.995, 1.05)1.03 (1.00, 1.06)*
    Households
    Years of residence in Mumbai
        Less than 1 year1
        1–5 years1.11 (0.52, 2.33)
        6 or more years0.92 (0.47, 1.81)
    Treatment of drinking waterb0.89 (0.74, 1.08)
    PPI: Likelihood below the US$2.16/day/PPP line2.06 (1.13, 3.74)*
    Private toilet0.89 (0.70, 1.14)
    Food insecurityc1.09 (0.88, 1.35)
    Religion
        Muslim1
        Hindu1.23 (1.01, 1.49)*
        Other1.12 (0.73, 1.73)
    SD (SE)0.433 (0.061)0.416 (0.061)0.356 (0.072)0.330 (0.077)0.325 (0.078)
    Intracluster correlation coefficient0.050.050.040.030.03
    • Abbreviations: PPI, Progress out of Poverty Index; PPP, purchasing power parity; SD, standard deviation; SE, standard error.

    • Statistical significance is calculated using mixed-effects logistic regression models.

    • ↵* P≤.05; ** P≤.01; *** P≤.001.

    • ↵a Model 1 adjusted for child characteristics; Model 2 adjusted for child and maternal characteristics; and Model 2 adjusted for child, maternal, and household characteristics.

    • ↵b Treatment of drinking water includes chlorine, use of filter, solar disinfection, and boiling.

    • ↵c Question: “In the last month did you worry that your household would not have enough food?”

    • View popup
    TABLE 6.

    Secondary Outcomes in Intervention Areas and Comparison Areas at Baseline (March–July 2014) and Endline (October–December 2015)

    BaselineEndline
    Intervention AreasIntervention AreasComparison Areas
    N%N%N%
    Timely initiation of breastfeeding (0–23 months)189937.0241737.2142449.5***
    Exclusive breastfeeding
    (<6 months)
    48848.667966.6***38566.0
    Continued breastfeeding
    (12–15 months)
    31574.045679.231483.1
    Timely complementary feeding
    (6–9 months)
    39848.040851.525257.5
    Introduction of solid foods
    (6–8 months)
    29351.530453.318156.9
    Minimum dietary diversity (6–23 months)150226.9186335.0***111530.5*
    Consumed vitamin A-rich foods (6–23 months)150224.8186320.5*111527.8***
    Consumed iron-rich foods (6–23 months)150229.6186340.1***111530.6***
    Fully immunized (9–23 months)120879.3155781.593472.2***
    Received at least 1 vitamin A supplement (9–23 months)120873.7155781.2***93471.3***
    Child received any service from ICDS in previous month, %257829.0345560.7***212229.6***
    Child received any service from MCGM in previous month, %257835.4345551.5***212233.4***
    • Abbreviations: ICDS, Integrated Child Development Services; MCGM, Municipal Corporation of Greater Mumbai.

    • Pearson chi-square tests comparing baseline intervention to endline intervention and baseline intervention to endline comparison areas.

    • ↵* P≤.05; ** P≤.01; *** P≤.001.

    • View popup
    TABLE 7.

    Demographics of Participants in Qualitative Study

    Staff Interviews
    Number13
    Age, years, mean (SD)35.2 (9)
    Female, %62.0
    Years of association with the program, mean (SD)2.7 (1.2)
    Focus Group Discussions With SNEHA Frontline Health Workers
    Number in each focus group discussion5 to 6
    Age, mean (SD)32.5 (8.5)
    Female, %81
    Years of association with the program, mean (SD)2.4 (1.2)
    Community Interviews
    Total number24
    Age of mother, mean (SD) (n=20)26.6 (4)
    No. of children in the family, mean (SD) (n=21)3 (2)
    Religion, %
        Hindu54
        Muslim38
        Christian8
    Cases severely wasted or moderately wasted, %63
    Cases with medical complications, %17
    Pregnant women, %17
    Case Stories
    Number46
    No. of children in the family, mean (SD) (n=39)3 (1)
    Type of Cases
        Non-wasted children, %21
        Severely wasted/moderately wasted, %54
        Pregnant, %9
        Complicated cases requiring holistic intervention, %11
        Others (contraception, family planning), %4
    • Abbreviations: SD, standard deviation; SNEHA, Society for Nutrition, Education and Health Action.

    • View popup
    TABLE 8.

    Strengths and Challenges of Key Program Activities as Reported by Stakeholders

    StrengthsChallenges
    Growth monitoring
    • Growth monitoring had become a regular and well-planned activity at the Anganwadi center.

    • Most mothers acknowledged the usefulness of growth monitoring.

    • Mothers conceded their inability to remember growth monitoring dates; hence, frontline health workers' repeated mobilization of the community was useful.

    • Most mothers were willing to bring their children for growth monitoring. Resistance to growth monitoring in the community mainly stemmed from practical difficulties (time, work pressure, and migration), rather than issues of cultural acceptance.

    Home visits
    • Home visits by frontline health workers were well-accepted and welcomed by the community.

    • Frontline health workers had been well-trained technically. In addition, most had been trained in and had acquired the soft skills for approaching households as well as for tailoring information.

    • There was considerable oversight of frontline health workers that also played a role in ensuring home visits happened regularly and appropriately.

    • Some severely wasted children required more visits than those required as per protocol; the frontline health workers often did not record why and when these additional visits were done in the monitoring software.

    • There was a need for training frontline health workers on information pertaining to the entire household rather than focusing on mothers alone.

    Health camps and referrals to NRRC
    • Health camps were held regularly.

    • The community perceived health camps to be useful, mainly due tothe easy access to free medicines and tonics.

    • Field staff felt that the main use of health camps was in confirming whether children were anthropometrically wasted or not.

    • The partnership with NRRC and the adjoining government hospital worked well for the program. The community often reported that frontline health workers referred them to the government hospitaland even accompanied them there if required.

    • Health camps, when established, were meant specifically for wasted children and pregnant mothers. But it was difficult for camps to turn away other sick children; hence, the camps were largely being used as general health camps for all children, which made them crowded.

    Provision of medical nutrition therapy
    • The logistics for supply and distribution of medical nutrition therapyin the program had been clearly set by the time of scale-up of the program. A checklist format had been developed for tracking medical nutrition therapy consumption of each child; these checklists were being monitored closely.

    • Consumption of medical nutrition therapy in the program was lower than expected. It was therefore difficult to make strong conclusions on the effectiveness of medical nutrition therapy in this context.

    • Overseeing compliance of medical nutrition therapy consumption by frontline health workers was challenging. Frontline health workers delivered several days of cups at a time to a child, but consumption by the child was self-reported by the mother.

    • While there were no serious issues with logistics (supply and storage) of medical nutrition therapy, there were mothers who found it difficult to feed the medical nutrition therapy cups to the severely wasted child for the full course of 56 days. Mothers and frontline health workers noted that some children got bored of the sweet flavor of the medical nutrition therapy and refused to eat it after a few days. There have been cases of children being pulled out of therapy due to persistent diarrhea or mere refusal to consume.

    • Abbreviation: NRRC, Nutritional Rehabilitation and Research Center.

    • View popup
    TABLE 9.

    Process Indicators in Intervention Areas (150 Anganwadi Centers)

    Activity for Child Under Age 3Monthly Average Oct 2014–Sep 2015
    Total children monitored7009
    Total moderately wasted in the program617
    Total severely wasted in the program112
    Children weighed each month4834
    Moderately wasted children receiving home visits443
    Severely wasted children receiving home visits89
    Children attending health camps289
    Children consuming medical nutritional therapy24
    • Source of data: Routine monitoring data of the program.

    • View popup
    TABLE 10.

    Quotes from Participants Illustrating Program Features Contributing to its Success

    ThemesIllustrative Quotes
    Constant field presence of staff“Now if the community does not see me for one day, next day I get a call—where are you? Sometimes the community people even directly come to our center to inquire where I am. (Male field staff, 27 years, employed with SNEHA: 1.5 years)
    “If anyone requires, we give our mobile number so that they can call us when they need any guidance or help. I had given my mobile number to her so she can call me if she has any problem—even in the night. She does not have a proper family support system.” (Female field staff, 34 years, employed with SNEHA: 2 years)
    “They are here only. They keep coming. They had visited here yesterday only; they gathered several women to explain to them … actually there was a meeting.” (Mother, 30 years, housewife, Muslim, 6 children, youngest girl, age 2 years, was severely wasted, recovered)
    “They mostly come quite often in a week, like they were here 2–3 days ago. They ask how we are. (Pregnant woman, 28 years, housewife, Christian, 2 kids)
    Information-sharing with the community through reinforcement and as a tailored process“… but doctors telling is different, their telling is different. Doctors are always in a hurry. They are under pressure because of patients, so they tell in shortcuts, some of it I understand and some I don't. These people (from SNEHA) are free, they tell us freely, each and everything, that you do this way. Then they come next day and ask whether we did the way we were told. Then we tell them that yes, we did. Then they again ask us after 1 week whether it was beneficial or not. It happens like this. And what will the doctors say, they just tell, whether we do it not, only we and our children are responsible. This is how doctors do it. And these people come and ask us regularly, ask us again after 1 week about whatever happened, whether the child is eating or not, whether the child is liking it or not, they ask us all of these. (Mother, 24 years, Muslim, 4 kids, 2 younger kids were severely wasted and 1 was on medical nutrition therapy)
    “SNEHA believes in giving messages, and individualization of messages was very important. So when you do home visits, there are 2 or 3 things which would help. Firstly, it was like you know a message for a particular person only, secondly you come to know the home situation also because there are times when the home situations are interfering with the actual process.” (Senior staff, other details masked to protect identity)
    “Today in the morning I visit one house. I found some bad smell was coming. So I will not tell immediately. First I will observe how that woman is. I will see the cleanliness in the house. While talking with her we see all how is kitchen maintained.” (Female field staff, 40 years, employed with SNEHA: more than 3 years)
    Persistence of field staff and collective persuasion“When she asked about the registration at that time she told that no, her husband has no time to pick up her to hospital. So she asked her father's mobile number. But they don't have that also. Then SNEHA frontline health worker asked for the neighbor's mobile number. The lady said okay. Then the next day, the SNEHA frontline health worker called her neighbor and spoke to her husband: ‘what is the reason why you did not register her for a pregnancy checkup?’ Then the program officer also called her husband and explained about the importance of the registration, medicine, everything. The next day the SNEHA frontline health worker, the ICDS frontline health worker, and the health post frontline health worker all went to her house and explained jointly. Then her husband took her to the hospital and did the registration. The continuous visits helped the family.” (Case study of a pregnant woman, age not known, Hindu, 3 children)
    “One family was not ready for immunization. Not even at a private clinic, since one of their relatives died after immunization, they said. The SNEHA frontline health worker spoke to the mother again and again. She agreed but her mother-in-law did not. We all went several times—me, the program officer, ICDS frontline health worker, and even our doctor visited to tell them. We all went together and told them. Then they agreed. (Female field staff, 35 years, employed with SNEHA more than 3 years)
    Holistic case management“When the SNEHA frontline health worker first identified the child, he was 3 months old. She oriented the mother regarding SNEHA and its work. The child had a cleft palate. The SNEHA frontline health worker spoke to the mother regarding her feelings for the child, ongoing treatment, and her difficulties faced while feeding the child. The mother replied that they had recently shifted to Mumbai as her husband worked here and mainly for the child's treatment. She did not know any hospital and was looking for one. While talking, she was upset and in tears. She said that all her relatives blame her for her child's condition and they say that he looks like a mouse. The SNEHA frontline health worker counseled her that it was a birth defect and can be successfully treated with surgery. She referred her to the hospital and screened the child. The mother fed breast milk to the child with a bowl and spoon. Sometimes the mother did get irritated, too, she shared, and felt bad and angry when other people came home to see the child and gave suggestions. When the mother shared her concerns, the SNEHA frontline health worker could feel her helplessness. The SNEHA frontline health worker asked the mother to calm down and said she understood her feelings. The SNEHA frontline health worker inquired about the father and the mother replied that he was nice, but due to family pressure, he also felt it was the mother's fault. The mother cried a lot. In the hospital, the doctors advised an operation. After the operation, the child could feed better. The mother started top feeds and the child gained weight. (Case story of an 8-month-old boy, cleft palate, migrant population, mother's age not known.)
    “The woman was mentally disturbed. She had a 3-month-old girl. She could not feed the child breast milk and so it was on top feed. The SNEHA frontline health worker visited her house many times and told her not to take stress. The woman said she had a problem with her family and her in-laws; and they were not accepting her. She wailed loudly—‘I am suffering because my husband is not accepting me,’ and she used abusive language. Our concern was that her small daughter will suffer because of this. This case was referred to the prevention of violence against women and children in SNEHA. The program counseled the entire family repeatedly. Now her family has understood and given her permission to live separately with her husband. (Case story of a new mother, 23 years, with a 3-month-old baby girl)
    • Abbreviations: ICDS, Integrated Child Development Services; SNEHA, Society for Nutrition, Education and Health Action.

    • View popup
    TABLE 11.

    Quotes from Participants Illustrating Successful Community Mechanisms in the Program

    ThemesIllustrative quotes
    Community felt cared for and supported“I remember how often we had to take [child's name] to the hospital, even in the rains. Now he is okay. Everyone in the neighborhood says that he's come back from death's jaw. There was no hope. His chest was full. [SNEHA frontline health worker] was here at that time, she walked in the rain and first took us to the small hospital, and then walked to the big hospital with us. She stayed until the admission process was over and then she left.” (Mother, 36 years, housewife, Muslim, 6 children, youngest boy, age 1.5 years, was severely wasted with pneumonia complications, recovered)
    “She [SNEHA frontline health worker] even took me along on 2–3 occasions to the hospital … because I wouldn't understand anything, hence she came along. There she accompanied me for 2 days, then I understood everything. Before I could get there, she would have the case paper ready and would show me the medicines … after that I'd return and she would stay back for some work.” (Mother, 25 years, housewife, Hindu, 2 children, younger girl, age 2.5 years, is severely wasted)
    “When they are not there, we have to manage on our own. When they [SNEHA frontline health workers] came, we felt a sense of support.” (Mother, 30 years, housewife, Muslim, 6 children, youngest girl, age 2 years, was severely wasted, recovered)
    Community believed that the knowledge imparted by the SNEHA frontline health workers was useful“This person from SNEHA, she comes daily … doctor comes once or 2 times a month … they advise us on weight and tell us about doctors. We get to know if child is not the right weight. We receive information so their visits are beneficial to us.”
    (Pregnant women, 25 years, housewife, Hindu, 1 girl, age 2 years, severely wasted, recovered)
    “They ask you to take care of the child, give them milk on time, feed them milk for 15 minutes on one side and then other … that the child should be fed milk 10–11 times through the day, and only then his weight will increase. Children should not be given any food from outside and you should start after 6 months. They should be given all the medicines on time.” (Mother, age not known, housewife, Hindu, 1 girl, age 3 months old, non-wasted)
    Community felt monitored“If they are there, it is good because then parents look after their children properly. They keep coming, so we also have to be attentive to our children.”
    (Mother, 30 years, housewife, Hindu, 2 children, younger boy, age 4 years, was severely wasted with complications, recovered)
    “If there is something that you may have forgotten to follow, you will instantly remember it after seeing them. Yes, because I don't feed him properly then how will he grow? That is why as soon as he wakes up in the morning I wash his hands and mouth and then give him milk and thereafter I give him something to eat. By that time what if someone comes to ask me what I fed him? That is why I feed him properly. We will also become careless … because we are being told [by the SNEHA frontline health worker] all the time, so we are attentive and we also fear that they might come anytime to ask us. Because of their visits we would know that today we are supposed to go to check the weight; otherwise, amidst these kids one tends to forget these things. It feels good because they come and call us.”
    (Mother, 25 years, housewife, Muslim, 4 children, twins were 11 months, girls, one of them was moderately wasted with complications of not walking)
    • Abbreviations: CMAM, community-based management of malnutrition; SNEHA, Society for Nutrition, Education and Health Action.

Additional Files

  • Figures
  • Tables
  • Supplemental material

    Files in this Data Supplement:

    • Download Supplement - Details about the SNEHA CMAM Program
PreviousNext
Back to top

In this issue

Global Health: Science and Practice: 6 (1)
Global Health: Science and Practice
Vol. 6, No. 1
March 21, 2018
  • Table of Contents
  • About the Cover
  • Index by Author
  • Complete Issue (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Global Health: Science and Practice.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation
(Your Name) has forwarded a page to you from Global Health: Science and Practice
(Your Name) thought you would like to see this page from the Global Health: Science and Practice web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation
Neena Shah More, Anagha Waingankar, Sudha Ramani, Sheila Chanani, Vanessa D'Souza, Shanti Pantvaidya, Armida Fernandez, Anuja Jayaraman
Global Health: Science and Practice Mar 2018, 6 (1) 103-127; DOI: 10.9745/GHSP-D-17-00182

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation
Neena Shah More, Anagha Waingankar, Sudha Ramani, Sheila Chanani, Vanessa D'Souza, Shanti Pantvaidya, Armida Fernandez, Anuja Jayaraman
Global Health: Science and Practice Mar 2018, 6 (1) 103-127; DOI: 10.9745/GHSP-D-17-00182
del.icio.us logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Statistics from Altmetric.com

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • PROGRAM DESCRIPTION
    • METHODS
    • RESULTS
    • DISCUSSION
    • CONCLUSION
    • Acknowledgments
    • Notes
    • REFERENCES
  • Figures & Tables
  • Supplements
  • Info & Metrics
  • Comments
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • Perceptions of healthcare providers and mothers on management and care of severely wasted children: a qualitative study in Karnataka, India
  • Evaluating malnutrition management through an intersectional lens: A case study of a community-based child malnutrition program in rural Uganda
  • Google Scholar

More in this TOC Section

  • People that Deliver Theory of Change for Building Human Resources for Supply Chain Management: Applications in sub-Saharan Africa and Southeast Asia
  • Exploring the Role of Gender in the Public Health Supply Chain Workforce in Low- and Middle-Income Countries
  • Applying a Theory of Change for Human Resources Development in Public Health Supply Chains in Rwanda
Show more ORIGINAL ARTICLE

Similar Articles

Subjects

  • Health Topics
    • Nutrition
Johns Hopkins Center for Communication Programs

Follow Us On

  • LinkedIn
  • Facebook
  • RSS

Articles

  • Current Issue
  • Advance Access Articles
  • Past Issues
  • Topic Collections
  • Most Read Articles
  • Supplements

More Information

  • Submit a Paper
  • Instructions for Authors
  • Instructions for Reviewers

About

  • About GHSP
  • Advisory Board
  • FAQs
  • Privacy Policy
  • Contact Us

© 2025 Creative Commons Attribution 4.0 International License. ISSN: 2169-575X

Powered by HighWire